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Two-dimensional power Doppler-three-dimensional ultrasound imaging of a cesarean section dehiscence with utero-peritoneal fistula: a case report
© Royo et al; licensee BioMed Central Ltd. 2009
Received: 21 July 2008
Accepted: 30 January 2009
Published: 30 January 2009
An imaging diagnosis after an iterative cesarean delivery is reviewed demonstrating a fine ultrasound-pathologic correlation.
A 33-year-old woman (G3, P3) presented referring intense dysmenorrhea and intermenstrual spotting since her third cesarean delivery, 1 year before. A cesarean section dehiscence with utero-peritoneal fistula was diagnosed by transvaginal ultrasound.
We can conclude that transvaginal two-dimensional power Doppler and three-dimensional ultrasound are highly accurate in detecting cesarean section dehiscence and uterine fistula.
The uterine fistula is a known and uncommon entity as a possible result of gynecological surgery or other pathologic conditions . The lower segment type of cesarean section has increased the prevalence of these uterine fistulous processes [1, 2]. An imaging diagnosis after an iterative cesarean delivery is reviewed demonstrating a fine ultrasound-pathologic correlation. Our objective is to report an unusual case of utero-peritoneal fistula in cesarean scar defect diagnosed by color Doppler hysterosonography and three-dimensional ultrasound.
Additional File 1: Video. Real-time B-mode and power Doppler video showing the blood moving between the hematoma and the endometrial cavity and which demonstrates the utero-peritoneal fistula. (AVI 9 MB)
Uterine fistulas are infrequent pathologic entities and are characterized by abnormal communication of the uterus with any other organ or structure through a perforation due to traumatic or infectious conditions . The lower segment type of cesarean section has increased the prevalence of these uterine fistulous processes, which account for 83% of cases [1, 2]. Rarely, it could be related to long labor, forceps delivery, vaginal birth after cesarean section, gynecological injuries, tuberculosis of the genital tract or intrauterine contraceptive devices . Our patient could not be considered as having Youseff's syndrome  because the bladder wall was not involved and, in addition, the three types of vesico-uterine fistulas defined by Jozwik and Jozwik were also ruled out . This case must be considered as an utero-peritoneal fistula, because the uterovesical pouch of peritoneum that covers the ventral surface of the uterus (separated from the bladder) was not affected.
The presence of the fistula can explain the symptoms referred by the patient during her menstrual cycle, with the passage of blood to the peritoneal cavity (causing peritoneal irritation with pelvic pain) and the vagina (causing intermenstrual spotting) . Transvaginal ultrasound and color Doppler hysterosonography have been used successfully in many cases to allow direct visualization of the uterine fistulae. It has been demonstrated that the normal sonographic appearance of the uterine incision as distinguishable from the abnormal appearance in patients who were symptomatic after cesarean section . Benacerraf et al.  showed three sonographic patterns for the uterine scar, including a dense, echogenic area; a fluid-filled area anterior to the site of the wound between the uterus and the bladder (our case); and a sonolucent area at the site of the wound between the external surface of the lower uterine segment and the lumen of the uterus. Transvaginal ultrasound is highly accurate in detecting cesarean hysterotomy scars. The cesarean scar defect, defined by the presence of fluid within the incision site, is more common when labor precedes cesarean delivery and with multiple cesarean deliveries .
The advantage of three-dimensional gynecological ultrasound (Figure 1) is the possibility of obtaining coronal planes and their surface reconstruction which provides new image features which are not possible to obtain with conventional two-dimensional ultrasound .
Conservative management may be attempted, especially for patients with few symptoms, as the tract may spontaneously close [7, 8]. The pregnancy rate after repair is 31.25% with a rate of term deliveries of 25% . After dehiscence repair, due to the high risk of uterine rupture or dehiscence, a new delivery should be performed by repeating a cesarean section [2, 7, 8].
Transvaginal two-dimensional power Doppler and three-dimensional ultrasound are highly accurate in detecting cesarean section dehiscence and uterine fistula.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We thank Dr Guillermo López García for his valuable suggestions.
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